Monday, February 12, 2018

Mental Health, Politics, and Social Justice

These are notes for a Public Lecture hosted by Chipping Barnet Labour Party on 12th February 2018.

I first tried to join the Labour Party before my 16th
birthday, and I think, even then, I called myself a socialist.

I’ve now been a clinical psychologist for 28 years.

I see these passions as intellectually, scientifically, and
conceptually linked.

When it comes to mental health...

In ‘a prescription for psychiatry’ I argue that:

Mental health problems are fundamentally social and
psychological issues...

That we should therefore replace ‘diagnoses’ with
straightforward descriptions of our problems, radically reduce use of
medication, and use it pragmatically rather than presenting it as a ‘cure’...

And that, instead, we need to understand how each one of us
has learned to make sense of the world, and tailor help to our unique and
complex needs. The well-established ethos of the clinical psychologist as
‘scientist– practitioner’ means that we can offer evidence-based scientific
models of both mental health problems and wellbeing.

Fundamentally, in my opinion, our thoughts, our emotions, our
behaviour and therefore our mental health, are largely dependent on our
understanding of the world - our thoughts about ourselves, other people, the
future, and the world.

This understanding, of course, has itself been, and
continues to be, shaped by our experiences. Things happen to us, we make sense of those events and
respond to them, and there are consequences. We all differ in the ways we
respond to events, and there are many reasons for those differences. There are
as many different reasons for these different responses as there are people in
the world. Biological factors, social factors, circumstantial factors – our
learning as human beings – affect us as those external factors impact on the
key psychological processes that help us build up our sense of who we are and
the way the world works.

That perspective has implications for mental health
services. To the extent that I think we can offer a MANIFESTO:

Mental health outcomes are getting worse in the United
Kingdom. While other areas of medicine have seen significantly improvement,
clinical outcomes in mental health have not improved and, according to some
measures, have fallen over recent decades. Additionally, UK mental health
disability rates have doubled over past 20 years, despite escalating
psychiatric prescriptions.

The bio-medical approach to mental health care is dominant
yet unsupported by the evidence. The biomedical approach rests upon scientifically
unfounded claims for the biological causes of mental health problems and a
selective and biased use of the evidence. This has led to excessive use of
medication and coercive treatment; increased mental health stigma, and
widespread misconceptions about the causes and most effective remedies for
mental health problems.

The bio-medical approach has led to an excessive use of
psychiatric drugs at great cost to the public purse. Approximately 18% of the
adult population takes a psychiatric drug on any given day, with prescriptions
of antidepressants doubling in the last decade. This costs the NHS around £800
million per year, with a large proportion being due to excessive, non-evidence
based, and unnecessary long-term prescribing.

Excessive long-term use of psychiatric drugs is causing
significant harm. There is now clear evidence that psychiatric drugs do not
cure mental health conditions but merely suppress symptoms. Like other
psychoactive drugs, long-term use is associated with poor outcomes and can
cause neurological damage. Withdrawal from psychiatric drugs can have severe
long-lasting consequences, which often lead to disability.

And...

Our services are fragmented, under-resourced and do not
deliver what people want. Current mental health services fail to invest
sufficiently in alternative yet more effective provision, including
psychological therapies, psychosocial care as well as support in the community
(rather than costly long-term hospitalization). Cost-effective psychosocial
options are under-resourced, difficult to access and poorly integrated with
other health and social care services.

Because of this, at least in my opinion, we need:

Appropriate funding of mental health and social care. Mental
health care clearly requires adequate funding, but we should avoid the ‘more of
the same approach’, which would merely see increasing funding for services with
poor outcomes. Instead, we should prioritise investment in effective
alternatives that will improve outcomes (including psychological therapies,
psycho-social support and early intervention and primary prevention) and shift
funding from ill-coordinated and fragmented bio-medical services to integrated
and whole-person care.

We need the promotion of accurate, non-stigmatising,
evidence-based approaches to mental health. Modern, scientific, accounts of the
nature and origins of mental health problems reject both a diagnostic account
of human distress and reductionist, bio-medical explanations. These accounts
are, in fact, not only scientifically incorrect, they lead both to higher (not
lower) levels of stigma and discrimination in the general public and to
passivity and hopelessness in people using mental health services. We must
therefore educate both members of the public and mental health professionals
about the nature and origins – and resolution – of mental health problems. This
includes greater understanding of psychosocial perspectives, leading to a
greater appreciation of the ability of all of us, with appropriate help, to
achieve greater positive mental health and a less passive, less patronising,
relationship with professionals.

We need to have services that focus on people, not
disorders. Such an approach would also emphasise fundamental human rights, most
particularly personal autonomy (control over our own choices) and the
protection of personal and family lives (things all too often threatened by
current approaches) and would involve substantial transfers of power – from
individual clinicians to teams, and from professionals to those of us who use
their services. This will involve, therefore, genuine co-production, and
leadership by users of services (defined both geographically and in terms of
demographic factors) at all stages of service design, commissioning and
management.

And we need effective services that people actually want and
need. The majority of people prescribed drugs would have preferred a different
intervention. We need to commission and invest in services that people demand
and would help them. These have to be effective, and therefore must
particularly emphasise those psychosocial interventions of proven efficacy.
Crucially, they should be the kinds of services that people choose – at
present, many people want access to psychological therapies, but are offered only
medication, and avoid other mental health services, leading to avoidable harm.
Finally, because mental health problems are, in many cases, intimately
connected to social and environmental causes, including abuse, bullying,
poverty, insecure employment or insecure housing, mental health services must
be more closely integrated with both physical health services (particularly
community, GP, services) and local authority social and educational services.
These services should prioritise prevention and early intervention, and work
more closely with services such as housing, education and the criminal justice
system.

This all has political implications.

The most powerful determinants of mental health are the
events and circumstances of people’s lives. If we are to protect people’s
mental health, we need wider social or even political change. This is often a
neglected topic, but social and political changes are likely to make much more
difference overall than anything individuals can do alone.

For example, the majority of people seeking help for
experiences such as hearing voices or paranoid anxiety have experienced
poverty. Addressing poverty is rightly the cornerstone of government, and few
politicians suggest differently (although many of us fear that right-wing
governments pay only lip-service to this aspiration, whilst presiding over
policies that actually increase inequalities). With a very specific focus on
mental health, however, measures to reduce or eliminate poverty, especially
childhood poverty, would be hugely beneficial.

Absolute income is not the only important issue. Evidence
shows that a major contribution to serious emotional distress is income
inequality – the growing gap between the richest and poorest people in society.
In their book ‘The Spirit Level’, sociologists Richard Wilkinson and Kate
Pickett demonstrate that mental health problems are highest in those countries
with the greatest gaps between rich and poor, and lowest in countries with
smaller differences. This suggests that an effective way to reduce rates of
mental health problems might be to reduce inequality in society.

Experiences of abuse in childhood are also hugely important
– and again associated closely with experiences such as hearing voices and
paranoia as well as self-injury, depressed mood and difficulties in maintaining
intimate relationships. Rates of mental health problems would plummet if we
found better ways of protecting children from abuse. This means working with
teachers, social workers, community nurses, GPs and the police to identify and
then respond to early warning signs that children might be exposed to sexual,
physical or emotional abuse or neglect. It also means taking a serious look as
a society at what we can do to bring down overall rates of abuse. Bullying –
that is, peer-on-peer bullying in school and in leisure settings – is also
important, and again here teachers and youth leaders could help...and thereby
help prevent later mental health problems.

But... clear in that account is the reference to the social
determinants of health and wellbeing. This is a question of why we behave as we do.

In my academic and professional role, we need to think a
little about what CAUSE means.

The causal pathway that results in a particular phenomenon –
hearing voices, depressed mood, anxiety – clearly involves our brain, our
biology, neuroscience. Neurotransmitter activity and the depolarisation of neurones;
chemical signalling, the expression of our genome and the biological
functioning of the brain as an organ of the body.

I genuinely have never come across anyone who disagrees with
that.

But perhaps what people really mean when they talk about ‘cause’
in the field of psychology or mental health is the explanation of INDIVIDUAL
DIFFERENCES.

Am I different to you – has my trajectory in life been
different to yours, or different to what it might have been – because of
inherent differences, even biological, genetic, differences, or because we have
been exposed to different life experiences, and learned different things from
them?

In 1967 Martin Luther King Jr spoke to the American
Psychological Association about links between racism, unemployment and living
conditions. Now, in 2018, we can see continuing economic crisis and the impact
of policies of austerity, right-wing populism and – most likely as a
consequence – Brexit.

And these are not just economic or political matters; they
are crucial psychological issues too. Quite literally, these are matters of
life and death. Between 2008 and 2010, immediately following the most recent
economic crisis – not yet the self-inflicted economic wounds of Brexit – there
were 1000 more suicides in England and Wales than would be expected on purely
historical trends, and many of those deaths can be attributed to rising
unemployment.

Psychologists, whose professional role is the promotion of
wellbeing and the prevention of distress, have a duty to speak out about those
social, economic and political circumstances that impact on our clients and the
general public, and to bring such evidence to politicians and policy makers.

For example, it’s clear that unemployment and exploitative
employment practices – zero-hours contracts, insecure jobs, the ‘gig economy’ –
are damaging to our wellbeing regardless of our age, gender, level of
education, ethnicity or the part of the country in which we live. The longer
someone remains unemployed, the worse the effect, and people do not adapt to
unemployment. Their wellbeing is permanently reduced. In contrast, re-employment
– finding a decent job if you are unemployed – leads to higher wellbeing.

Martin Luther King said: ‘There are some things in our
society, some things in our world, to which we should never be adjusted.’
Another Nobel Prize winner, Albert Camus (distinctive in that he occupied
himself during the Nazi occupation of France editing the clandestine newspaper
of the Resistance) wrote in his private notebook in May 1937: ‘Psychology is
action, not thinking about oneself.’

Psychologists study why people behave as they do. We are
therefore uniquely placed to help understand and address some of the most
pressing problems facing humankind. Our expertise brings with it an ethical
duty to follow the lead of Camus and King and speak out about those issues that
demand a voice. We should be clear that human beings are products of our
society. We should explore and explain, using our distinctive science, the
mechanisms by which the events and circumstances of people’s lives can lead to
psychological problems.

So... what do we do?

Well, I’m here at a political event, so I’ll focus on that.

But clinical psychologists are – nearly all – employed in
the NHS, so it’s worth just mentioning the contractual expectations on us from
our employers – the NHS Trusts, the Secretary of State for Health and Social
Care, and, ultimately, citizens.

A genuinely psychosocial approach to service delivery would
mean increased investment in the full range of professionals able to deliver
therapeutic services that address people’s genuine problems and their root
causes. The service would offer help with a spectrum of psychological
difficulties rather than only those deemed ‘mental health problems’.

There would be a major emphasis on prevention. We need to be
able to address such issues as divorce, marital difficulties, unemployment,
stresses at work, financial difficulties, illnesses in family members, crime
(both as a victim and as a perpetrator, when caught up in the criminal justice
system), assaults, bullying, and childhood abuse.

Clearly, we need to offer psychological therapies, because
we know that the way that people make sense of and respond to events is
important, and the opportunity to talk through what has happened and how it has
affected us is vital. But we also need to offer much more practical responses.
As my colleague Anne Cooke put it: ‘It’s no good just mopping the floor and
leaving the tap running’.

So mental health and well-being services should need to work
with the criminal justice agencies to ensure both protection and justice –
investigating and preventing assaults. Because marital separation is a major
source of emotional stress, we should ensure that there is sufficient support
for people going through separation or marital difficulties, such as mediation
services, support for single parents, and practical, legal and emotional
support for people in difficulty in their relationships.

Because unemployment is a major source of distress, we
should aim for full employment, and certainly do what we can to protect people
from the emotional and economic impact of unemployment.

Many jobs are themselves sources of stress, however. We
should aim to ensure equitable and supportive employment practices, including
employee relations, a living wage, decent terms and conditions and appropriate
employee representation. We should engage with employers to address workplace
stresses and offer people who are out of work practical, as well as emotional
support.

Services such as Citizens Advice, debt counselling agencies
and Victim Support are vital to help people in financial difficulties, victims
of crime and people dealing with a range of other traumatic life events. We
should ensure that any mental health and well-being services are fully
integrated with other social services that support families and parents in
difficulty.

It also means working with teachers and educational
psychologists in schools, and it means supporting a network of children’s
services. We should not only offer emotional support, and counsel people in
financial difficulties, we should also offer people practical help and
financial advice. We should support people in negotiations with benefits
agencies to ensure people have the financial support that they deserve, and we
should be prepared to engage with financial systems (such as ‘pay-day loan’
companies) that conspire to keep people indebted. Recreational street drugs can
prove a threat to people’s mental health and well-being, and so we should
ensure that mental health services have intimate links to services that help
people who have problems with drug use.

Clearly, providing these services properly will entail
significant change. Many of these issues are currently largely ignored, and most
are ill-coordinated. Apologists for the present systems will argue that all
these services are currently part of the care offered to clients. The
experiences of those who have passed through the system would tend to suggest
otherwise.

Our mental health and well-being are largely dependent on
our social circumstances. To promote genuine mental health and well-being we
need to protect and promote universal human rights, as enshrined in the United
Nations’ Universal Declaration of Human Rights. Because experiences of neglect,
rejection and abuse are hugely important in the genesis of many problems, we
need to redouble our efforts to protect children from emotional, physical or
sexual abuse and neglect. Equally, we must protect both adults and children from
bullying and discrimination: whether that is racism, homophobia, or
discrimination based on sexuality, gender, disability or ‘mental health’ or any
other characteristic. We can all do more to combat discrimination and promote a
more tolerant and accepting society.

More generally, if we are serious about preventing mental
health problems from developing, and about promoting genuine psychological
well-being, we must work collectively to create a more humane society: to
reduce or eliminate poverty, especially childhood poverty, and to reduce
financial and social inequality. We need to work harder to promote peace,
social justice and equity, and ensure that citizens are properly fed, housed,
and educated, and living in a sustainable natural ecosystem. We need to promote
social mobility and social inclusion, encourage actions aimed at the common or
collective good (for instance through practical support of local charitable
activities), and reduce both corruption and materialistic greed. In a fair
society, in a society that protects our mental health and well-being, we would
ensure that everyone had a meaningful job or role in society and we would
eliminate unhealthy organisational cultures at work.

We can also see good arguments for change at the level of
commissioners and policy-makers.

Psychosocial codes, which are already part of both the World
Health Organisation’s ICD-10 and the American Psychiatric Association’s DSM-5,
incorporate descriptive information regarding adverse life experiences and living
environments, but are almost never used or reported in clinical practice or
academic publications. These quasi-diagnostic codes document issues such as;
neglect, abandonment, and other maltreatment, homelessness, poverty,
discrimination, negative life events in childhood, including trauma, problems
related to family upbringing, and housing and economic problems.

Preliminary data – from North London, as it happens –
suggests that such codes – which clearly apply in the vast majority of cases –
are recorded in as few as 7% of occasions. 93% of people simply do not have the
root causes of their problems recorded. And ignoring these social determinants
of mental health problems can only serve to locate the blame NOT in those
unacceptable social circumstances, but – unjustly – in the individual.

Broadening routine data capture within UK National Health
Service records could establish more inclusive, social, systemic, and
psychologically comprehensive patterns of difficulties, which could target
information regarding established social determinants of mental health
problems, such as inequality, poverty, and trauma. Imagine if it were as
serious to fail to document extreme poverty as it would be for a clinician to
fail to identify severe depression.

So...

As I look at the world – at the world at large as well as at
the world of mental health – I see people making sense of the things that have
happened to them.

We’re using that miracle of evolution – the human brain – to
learn, on a deep an implicational level, from the events, the circumstances,
the context of our lives.

If we’re told we’re worthless, stupid, ugly, or merely pawns
to be used – by abusers or oligarchs – then we’ll learn from that... and the
consequences are obvious.

So, for me, a humane, right-based, intelligent,
psychological position on mental health is – sorry – a social-determinist
approach... and that brings me back to my political views.

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